Approach * Acute febrile syndrome - is caused by a number of diseases. * Illness’ to be distinguished from each other with sufficient accuracy to guide treatment that will address the cause, and to provide information needed to plan and prioritize. This may require: * Case-managementtests (tests to guide treatment where patients first seek care) * Screening tests (tests to identify the most common pathogens in a population to guide presumptive therapy and planning)Approach- diagnosis of Fever L * Diagnosis by prevalence * Count the duration of fever by day * Try find the organ of origin of fever- Associated symptoms are the key * Athorough systemic enquiry is essential * Temporal profile of fever should be identified * Dose, duration, dates, route & compliance of previous antibiotics essentialAssessment Steps * Step 1: Assess severity of symptoms and recognize sepsis - fever, tachycardia, tachypnea, or hypotension can provide key clues for systemic inflammatory response syndrome (SIRS) or sepsis * Step 2: History and clinical examination to assess for localization of fever-Fever with Nonspecific laboratory finding Bandemia With Normal WBC » Severe typhoid fever » Malaria » Severe Viral Infection » Hemorrhagic Fever VirusesBed-side Clues are most important ¢ Fever With Localizing Signs ¢ Fever Without Localizing Signs ¢ Fever With Nonspecific SignsHigh grade fever Flu Meningitis & Encephalitis Sepsis Malaria Infective endocarditis MDR typhoid fever Pneumonia Viral hemorrhagic fever TSS Leptospirosis Juvenile Rheumatoid arthritis Neuroleptic Malignant Syndrome.Values for WBC * WBC counts > 15,000 are associated with SBI —Sensitivity 40 - 52%, Specificity 76 - 84% —Likelihood ratio 2.11 - 2.5 in infants < 2 months — Area under ROC 0.70 in infants < 2 monthsCRP * Acute-phase reactant * Sensitive indicator of infection * Shown to have a better predictive value than WBC or ANC for bacterial infection * ACRP <5 mg/dl (50mg/L) effectively ruled out serious bacterial infectionCollagen-vascular diseases * Rheumatic Fever ¢ Juvenile Rheumatoid Arthritis (JRA) * Kawasaki’s diseaseFever and ESR > 100 mm/hr . Sepsis Abscess TB Osteomyelitis Infective endocarditis Kala azar Lymphoma Leukemia Collagen vascular diseases Multiple myeloma Subacute thyroiditisESR Erythrocyte sedimentation rate determination is a commonly performed laboratory test with a time-honored role, however the usefulness of this test has decreased as a new method of evaluating diseases have been developed. The test remains helpful in the specific diagnosis of a few conditions including temporal arteritis, polymyalgia rheumatica and possibly rheumatoid arthritis and multiple myelomaEvaluation * CBC —White blood count (WBC) has been recommended as a screening tool since 1970s — WEC remains a useful screening tool * Rapid to perform * Widely available —Total WBC count, absolute neutrophil count and absolute band counts have all been shown to be associated with SBI. Fever Patterns tl Hyperpyrexia (suggestive of intracranial hemorrhage, septicemia, Kawasaki disease, thyroid storm, drug fever, Heat injury) Hectic or spiking pattern (suggestive of biliary or urinary tract infection, endocarditis) Saddleback pattern (suggestive of dengue fever, leptospirosis, poliomyelitis, human granulocytic ehrlichiosis) Morning temperature spikes (s/o typhoid fever, tuberculosis, polyarteritis nodosa)Fever with Anemia Malaria Incidental pre-existing anemia Bartonellosis BabesiosisFever and shaking chills Pneumonia Sepsis Malaria Absceses Legionaires disease Pylonephritis Bacterial endocarditis Filariasise Diagnostic Clues i Fever with anemia Fever with jaundice Fever with an obvious rash Fever with lymphadenopathy Fever with white blood cell abnormalities —Eosinophilia —Neutrophilia —NeutropeniaFever with Jaundice * Viral hepatitis * Epstein-Barr virus (infectious mononucleosis) * Malaria * Typhoid * Leptospirosis * CytomegalovirusFever with Lymphadenopathy * Fever and Cervical Lymphadenopathy — Primary toxoplasmosis — Bartonella (cat scratch disease) — Atypical TB * Fever and Generalized Lymphadenopathy — Epstein-Barr virus (infectious mononucleosis) — Trypanosomiasis (parasitic protozoan trypanosomes) — Toxoplasmosis, HIV infection, Filariasis — Leptospirosis, Leukemia/lymphoma, Juvenile rheumatoid arthritis — Drug reactions, Secondary syphilisFever and monocytosis ( > 950mcl) Infective endocarditis TB Brucellosis Solid tumor Hodgkin’s diseases .B.D = Rockymountain spotted fever ener Monocytic leukemia Syphilis Sarcoidosis MalariaFever With Nonspecific Signs » Fever and splenomegaly » Fever and anemia » Fever and abdominal mass » Fever and hepatomegalyFever with an Obvious Rash Meningococcemia Rickettsial spotted fevers Viral hemorrhagic fevers Dengue and similar arboviruses Leptospirosis Secondary syphilis Collagen-vascular disease and drug reactionsFever with underlying diseases » Fever in the Neutropenic cancer patients » Fever in the Diabetic patients » Fever in the Alcoholic patients » Fever in intravenous drug users » Fever in the HIV infected patients » Fever in the patients with splenectomyFever with White Blood Cell Abnormalitie * Eosinophilia — Fasciola hepatica (liver fluke) — Filariasis (roundworm) — Visceral larva migrans (roundworm) — Trichinosis (roundworm) — Severe strongyloidiasis (roundworm) — Drug reactions * Neutrophilia — Pyogenic abscess Leptospirosis (a spirochaete bacterium) — Relapsing fever (louse-born bacteria Rickettsia and Borrelia) — Amebic liver abscess — Collagen-vascular disease * Neutropenia Viral i fections, Rickettsial infections, TyphoidFever Without Localizing Signs Malaria Md Septicemia Malignancy Typhoid * Particularly consider if fever persists >7 days and malaria has been excluded * Complications: acute abdomen, coma, convulsions, cardiac failure, shock Urinary Tract Infection Infection Associated with HIV Other protozoa * Babesiosis (parasitic disease via ticks) + Toxoplasmosis (parasitic disease from protoazoan) Bartonella species + Carrion’s disease (Peruvian warts via sandflies); Cat scratch disease Arboviral fevers + Dengue fever Hemorrhagic fevers * Lassa fever, Marburg virus disease, Ebola virus disease, Dengue hemorrhagic fever gioun, tieeCiinenn tower:Day 1or2 Differential count, Malaria parasite quantitative buffy coat, urinalysis Maj Follow Sepsi Day 5 or greater As per day 3 or 4, plus blood culture Antimicrobials based inical judgement. “|General Management Principle: * Focus on life-threatening / Organ-threatening conditions. * Be empathetic. * Place in a position of comfort. * Treat for dehydration.indications for hospitatization All emergency patients in need for airway stabilization, ventilation or continued O02 requirement Age <28 days Prolonged seizure/status epilepticus Altered sensorium Electrolyte imbalance Signs of Severe Dehydration Not feeding well Respiratory distress SPO2 <90% in room air Drug toxicity or drug reaction Unknown or undetermined cause Concern for non-compliance or inability to followupIntermittent Fever * Intermittent fever (suggestive of malaria, kala- azar, pyaemia) * Double quotidian fever (suggestive of Still's disease, legionellosis, miliary tuberculosis, kala-azar) * Quotidian fever (suggestive of Plasmodium falciparum or Plasmodium knowlesi malaria) * Tertian fever (suggestive of Plasmodium vivax or Plasmodium ovale malaria) * Quartan fever (suggestive of Plasmodium malariae malaria)Fever with Leukopenia » Malaria - TB » Brucellusis * Typhoid Fever » Kala-azar ~ Sever sepsis ~ Viral infection. Look for Signs of Severity Severe Tachycardia Tachypnoea Respiratory Distress Oxygen Saturation < 90% Shock Altered Mental Status Petechial or Purpuric rash Meningeal signs Seizures Heart Murmurs Severe Abd. Pain Dehydration Critically Ill appearance Bulging Fontanelle in Young Temp > 106Other potential markers Band counts ANC Band to Neutrophil ratio ESR C reactive Protein Pro-calcitoninPyrexia (fever) can be classed as- * Low grade: 38—-39°C (100.4—102.2°F) * Moderate: 39-40°C (102.2—104.0°F) * High-grade: 40—42°C (104.0-107.6°F) * Hyperpyrexia: Over 42°C (107.6°F) ¢ Febricula is a mild fever of short duration, of indefinite origin, and without any distinctive pathologyRelapsing fever Relapsing fever (Borrelia 2-3 weeks) Malaria Rat bite fever (3- 5 days) Charcot’s intermittent fever FMF Cyclic Neutropenia (21 days) Pel Ebstein Fever (Hodgkins, Brucellosis 7- 10 days)Fever With Nonspecific Laboratory Finding Leukocytosis ,Neutrophilia & Bandem » Sever sepsis » Sever pneumonia » Meningitis » Infective endocardaitis » Some time complicated sever viral infectic » Hemorrhagic fever viruses * Toxic shock syndrome » Sever abdominal infection -Assessment Steps * Step 3: Use Rapid diagnostic tests for early diagnosis of Malaria and Dengue * Step 4: Use anti-pyretics alone if fever is less than three days in duration and initial RDTs are negative-Assessment Steps * Step 6: Acute undifferentiated fever with negative culture that persists despite initial empiric antibiotics- Thorough InvestigationsSustained fever k » Lobar pneumonia (pneumococcal) » Rickettsial diseases » Drug fever » Typhoid fever » Typhus » CNS damageInvestigation aide- When to test, Whom to test and Which tests.. First three days--usually investigations are not required unless it Is definitely indicated Uncomplicated/ not sick — Short Febrile Illness / ILI -no need for investigation If the patient looks ‘sick’, or has ‘unusual’ symptoms at any time--- do appropriate investigation. If area has reports of any specific/ endemic diseases (Lepto/ Malaria/ DF/ AES/ scrub typhus)—specifically screen for such diseases among patients coming from such areasWhat is the DDx? i. Emergency treatable diseases ~. Non-emergency treatable diseases +. Non-emergency non-treatable diseasesWBC as a marker * Clearly associated with increased risk of bacteremia at values < 5000 (likelihood ratio of 3.9) >15,000 (likelihood ration of 2.0) * However known to have poor sensitivity and specificity and thus inaccurate * Because of its low predictive value and the low prevalence of bacteremia —Results in unnecessary treatment in 85-95% of cases ~Approach All febrile patient who are toxic-appearing should be hospitalized for evaluation and treatment of possible sepsis or meningitis Toxic-appearing: — Lethargy + (Level of consciousness characterized by poor or absent eye contact or as the failure of a child to recognize parents or interact with persons or objects in the environment) — Signs of poor perfusion or marked hypoventilation — Hyperventilation — Cyanosis — The toxic patient always mandates aggressive work-up, abx and admissionApproach to the patient with cull » Fever and age » Fever pattern » Duration of fever » Feverin returning travelers » Pattern syndrome » Fever with underlying diseases » Fever with nonspecific signs » Fever with focal signs & symptoms » Fever of unknown origin » Fever with nonspecific laboratory findingaE RAR ON, oF OR Saar a eRe: life threatening infectious associated with diabetes » Rhinocerebral mucoromycosis » Malignant otitis externa » Emphysematous cholecystitis » Emphysematous pyelonephritis » Necrotizing fasciitis » Sepsis